Considering the advantages and the disadvantages of the approaches to treating atrial fibrillation (i.e., restoring and maintaining a normal rhythm vs. controlling the heart rate in atrial fibrillation ), where does this leave you if you have atrial fibrillation? This question is best answered by first considering what pattern of atrial fibrillation you have.
Patients with atrial fibrillation generally fall into one of two broad categories: those with occasional episodes of atrial fibrillation (paroxysmal atrial fibrillation), or those with chronic or persistent atrial fibrillation.
If You Have Paroxysmal Atrial Fibrillation:
Description of this condition: These patients are in a normal heart rhythm most of the time, but they have episodes - lasing minutes to hours - in which they are in atrial fibrillation. The symptoms they experience with these episodes can be relatively mild or relatively severe, and the frequency of episodes varies tremendously from patient to patient.Treatment: In general, the goal of therapy if you are in this group is to maintain a normal heart rhythm. You should avoid those foods and substances that are known to precipitate atrial fibrillation in some people - caffeine and other stimulants, tobacco, and alcohol. Alcohol is particularly important in some individuals, in whom even a single drink can precipitate atrial fibrillation (the so-called "holiday heart syndrome").
When you have an episode of atrial fibrillation, you can wait for up to 6 hours to see if it stops on its own. If it does not, get medical attention. Make sure the doctors get you back into a normal rhythm within 12 to 24 hours (don't let them take the "wait and see" gambit too far), because blood clots begin to form in the atria after this much time has passed. If you do not convert to a normal rhythm on your own, insist that they cardiovert you before 24 hours has passed.
If you have frequent episodes of atrial fibrillation lasting more than 12 hours or so, discuss the need for anticoagulation with your doctor. Medical science is not definitive on this point, but many doctors believe that people with such episodes need to be anticoagulated to reduce the risk of stroke - and they may be right.
If your episodes of atrial fibrillation are frequent, you may also wish to discuss a trial of antiarrhythmic drugs with your doctor. These drugs may significantly reduce the frequency or duration of your episodes, even if they do not abolish them, and in some cases taking the risk of using these drugs in order to prevent frequent or disabling symptoms is quire reasonable.
If You Have Chronic or Persistent Atrial Fibrillation:
Description of this condition: When these patients have episodes of atrial fibrillation, the arrhythmia tends to persist for at least a day, and may persist indefinitely until cardioversion is performed. After cardioversion, the normal heart rhythm remains for variable lengths of time. But when atrial fibrillation recurs, it is again prolonged in duration.Treatment: Most doctors will try restoring and maintaining a normal heart rhythm at least once or twice in these patients. A trial of cardioversion followed by watching and waiting is appropriate. If the atrial fibrillation recurs, then another cardioversion may be performed, this time along with a trial of an antiarrhythmic drug. If the drug fails, then it is time to consider either more drug trials, or letting the atrial fibrillation persist, and treating with rate control measures (including AV node ablation and pacemaker implantation, if necessary.)
Virtually all these patients should be on chronic anticoagulation therapy, unless there is a good reason to avoid it, or unless a normal rhythm has been maintained for at least 6 to 12 months.
If the patient falls into a category where restoring and maintaining a normal heart rhythm is a must, then aggressive trials with antiarrhythmic drugs are indicated, and if all these drug trials fail, then more aggressive ablation procedures aimed at abolishing the atrial fibrillation (such as ablation) should be considered. An electrophysiologist should be consulted in this situation.
Is Maintaining a Normal Rhythm Better than Rate Control?
At this point, the answer appears to be "no." In fact, two large randomized controlled clinical trials comparing rhythm control with rate control in patients with atrial fibrillation have now been completed, and probably against what most would predict, both of these studies showed a trend toward worse patient outcomes (including the incidence of death, heart failure, stroke and bleeding) with the rhythm-control approach. Most attribute these worse outcomes to the side effects of antiarrhythmic drugs, but this is unclear.
Bottom line: For now, the "default" approach for most patients with chronic or persistent atrial fibrillation (after one or perhaps two attempts to maintain a normal rhythm have failed) is the rate-control approach.
Sources:
Wyse DG, Waldo AL, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Eng J Med 2002;347(23):1825.
Van Gelder IC, Hagens VE, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Eng J Med 2002;347(23):1834.
